Journal of
Personalized
Medicine
Article
Effects of Pain Neuroscience Education Combined with Lumbar
Stabilization Exercise on Strength and Pain in Patients with
Chronic Low Back Pain: Randomized Controlled Trial
Ki-Sang Kim 1 , Jungae An 1 , Ju-O Kim 1 , Mi-Young Lee 2






Citation: Kim, K.-S.; An, J.; Kim, J.-O.;
Lee, M.-Y.; Lee, B.-H. Effects of Pain
Neuroscience Education Combined
with Lumbar Stabilization Exercise
on Strength and Pain in Patients with
Chronic Low Back Pain: Randomized
Controlled Trial. J. Pers. Med. 2022,
12, 303. https://doi.org/10.3390/
jpm12020303
Academic Editor: Amelia Filippelli
Received: 6 December 2021
Accepted: 11 February 2022
Published: 17 February 2022
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Attribution (CC BY) license (https://
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4.0/).
J. Pers. Med. 2022, 12, 303. https://doi.org/10.3390/jpm12020303
and Byoung-Hee Lee 2, *
1 Graduate School of Physical Therapy, Sahmyook University, Seoul 01795, Korea; kgs4590@naver.com (K.-S.K.);
jungaean@hotmail.com (J.A.); k_juo@naver.com (J.-O.K.)
2 Department of Physical Therapy, Sahmyook University, Seoul 01795, Korea; mylee@syu.ac.kr
* Correspondence: 3679@syu.ac.kr; Tel.: +82-2-3399-1634
Abstract: Chronic low back pain that lasts more than 12 weeks causes mental and physical distress.
This study investigated the effects of pain neuroscience education combined with lumbar stabilization
exercises on strength, pain, flexibility, and activity disorder index in female patients with chronic
low back pain. Thirty-five female patients with chronic low back pain were randomly divided into
two groups: the pain neuroscience education (PNE) combined with lumbar stabilization exercises
(LSEs) group (n = 18, experimental group) and the lumbar stabilization exercises alone group (n = 17,
control group). The experimental group underwent PNE combined with LSEs for 30 min per
session, twice per week for 8 weeks, and the control group underwent LSEs only. The primary
outcomes were strength (sit-up and back-up movements), Numerical Pain Rating Scale (NPRS),
Korean Pain Catastrophizing Scale (K-PCS), and Tampa Scale of Kinesio-phobia-11 (TSK-11) for
pain. The secondary outcomes were modified–modified Schober’s test (MMST) and finger to floor
test (FFT) for flexibility and activity disorder (Roland–Morris Disability Questionnaire index). A
significant difference was observed in the primary outcomes after intervention in the abdominal
muscle strength (group difference, mean, −7.50; 95% CI, −9.111 to –5.889, F = 9.598; ANCOVA
p = 0.005), the back muscle strength (group difference, mean, −9.722; 95% CI, −10.877 to –8.568,
F = 7.102; ANCOVA p = 0.014), the NPRS (group difference, mean, 1.89; 95% CI,1.65 to 2.12, F = 24.286;
ANCOVA p < 0.001), K-PCS (group difference, mean, 7.89; 95% CI, 7.02 to 8.76, F = 11.558; ANCOVA
p = 0.003), and TSK-11 (group difference, mean, 16.79; 95% CI, 13.99 to 19.59, F = 13.179; ANCOVA
p = 0.014) for pain. In the secondary outcomes, there was a significant difference in the FFT (group
difference, mean, −0.66; 95%CI, −0.99 to −0.33, F = 4.327; ANCOVA p = 0.049), whereas the difference
in flexibility (MMST) and activity disorder index of the secondary outcomes did not reach significance.
Therefore, this study confirmed that PNE combined with LSEs is an effective intervention compared
to LSE alone in improving muscle strength and pain in female patients with chronic low back pain.
Keywords: neuroscience; patient education; muscle strength; pain
1. Introduction
Low back pain is a common condition that affects the lives of many people, leading
to high treatment costs, sick leave, and pain. It is the cause of one-fifth of all hospital
visits and >80% of adults experience low back pain more than once in their lifetime [1].
Around 5~10% of low back pain progresses to chronic low back pain, mainly in women
older than 40 [2,3].
Chronic low back pain usually refers to pain lasting more than 12 weeks and is
associated with physical pain and fatigue from daily activities; it causes mental distress such
as stress, depression, anxiety, impaired performance, and sleep disorders [4]. The causes of
low back pain include changes in lifestyle habits, changes in the work environment, lack
of exercise among modern people, and muscle weakness and decreased flexibility due to
https://www.mdpi.com/journal/jpm
J. Pers. Med. 2022, 12, 303 2 of 14

imbalance of the muscles around the lumbar region [5]. Among the epidemiological causes
of low back pain, the most important is spinal instability [6], which causes pain, decreased
endurance, decreased flexibility, and limitation in the range of motion of the lower back [7],
and progresses to a chronic state. As the cross-sectional area of the muscles around the
spine decreases, irreversible atrophy occurs.
The symptoms of low back pain are typical pain sensations in the lower lumbar region
that occur frequently, such as dull pain, sharp pain, and aching pain [8]. When low back
pain occurs, the sensitivity of the body increases [9], and its symptoms decrease the overall
body activity owing to pain sensation, structural damage, and inhibition of the reflex
contractile mechanisms of muscles. This leads to atrophy and muscle weakness, which
worsen back pain and cause secondary spinal damage and physical disability [10].
Low back pain is treated using the Mulligan technique [11], manual traction with
orthodontic treatment [12], thermal therapy and electrotherapy [13], and medications [14].
Physical inactivity negatively affects recovery from chronic low back pain, whereas exercise
such as lumbar stabilization exercises (LSEs) has an effect in reducing pain and improving
disability [14,15]. At present, LSEs are considered effective for improving health in patients
with chronic low back pain, increasing the stabilization of the spine by training the move-
ment pattern of the muscles [16], thus considerably reducing back pain. In addition, LSEs,
which play an important role in providing dynamic stability to spinal segments, are useful
for reducing dysfunction due to instability of the spine by strengthening the local muscle
groups located in the deep trunk [6].
Recent low back pain is related not only to simple pain or dysfunction but also to psy-
chosocial problems such as depression and poor quality of life [17]. Various physiological
and psychological factors can be proposed as causes, and one possible cause is a direct
injury [18]. Patients with chronic low back pain may experience psychological anxiety and
depression due to physical and psychological stress resulting from limitations in physical
activity [19]. Dysfunction in patients with chronic low back pain is highly associated with
fear of pain and fear of movement. Pain neuroscience education (PNE) is an educational
approach that deals with the nervous system in general and the physiology of the pain
system, and has been conducted in patients with chronic musculoskeletal disorders such
as chronic low back pain to address their thoughts and attitudes about pain for clinical
effectiveness [20,21]. PNE does not solely focus on histopathology, but also on redefining
the concept of pain by providing information about neurobiological and physiological
processes based on the patient’s pain experience. Such attempts at reconceptualization help
in understanding that pain and tissue damage are different concepts [22,23].
Although several studies have shown that the changes and improvements in functional
and symptomatic outcomes with physical therapy and the application of PNE are effective
in reducing pain and improving dysfunction [24,25], high-quality studies on PNE and
exercise combinations for chronic low back pain are still needed because of the diversity
of interventional exercise types, PNE application methods, and participants in previous
studies [26,27].
Therefore, the purpose of this study was to compare the effects of PNE combined with
LSEs on muscle strength, pain, flexibility, and activity disorder index in female patients
with chronic low back pain.

2. Materials and Methods

2.1. Participants
This study was conducted on female patients aged 60 to 70 years old who visited C
Hospital in Seoul, Korea, for chronic low back pain. The inclusive criteria for the study
were as follows: active participation in the study, sufficient understanding of the study,
completion of the study consent form, voluntary participation in the study, and a diagnosis
of nonspecific chronic low back pain related to neurological abnormalities by the doctor in
charge based on radiographic examination. Those who had a prevalence period of at least
3 months after the diagnosis were also considered.
J. Pers. Med. 2022, 12, 303 3 of 14

The exclusion criteria for the study were as follows: motor and sensory dysfunction,
neurological abnormalities, muscle paralysis, doctor’s orders to refrain from exercising,
limited range of motion due to acute lumbar pain, and mental problems or inability to
understand the study. Patients with difficulty in participating correctly, those with dizziness
or hypertension (blood pressure of ≥160/110 mmHg), and those who could not take the
basic posture of LSEs because of pain were included.
The present study was approved by the institutional review board of Sahmyook
University (Seoul, Korea, 2-1040781-A-N-012020081HR) and it was registered (KCT0005499)
in the Clinical Research Information Service of the Republic of Korea. The objective and
procedures of the study were fully understood by the participants, and all participants
provided informed consent for inclusion. This study was performed in accordance with
the ethical principles of the Declaration of Helsinki.

2.2. Experimental Procedures

We used G*Power (version 3.1.9.7; Franz Faul, Kiel, Germany, 2020) for power analysis
before recruiting participants. The overall effect size index for all outcome measures and the
power of the study were 0.5 and a probability of 0.05 to minimize type II error (80% power),
respectively. The estimated target sample size was 34; therefore, we recruited 40 low back
pain patients for this experiment.
The 40 participants who met the selection conditions provided consent after receiving
detailed explanations of the experimental procedure. After the pre-test, all participants were
randomly divided into two groups which performed PNE with LSEs (n = 20) or the control
group (n = 20), which performed LSEs alone using the Research Randomizer program
(http://www.randomizer.org/, accessed on 25 September 2020). To blind participants
to group allocation, they were only informed about the general description of the study
design. However, they were not informed about the type of intervention. All tests were
measured by physical therapists who were not involved in this study, and to minimize the
measurement error, the same examiner performed the measurements before training and
after 8 weeks of training.
All participants were evaluated for strength, pain, flexibility, and activity disorder
index before and after training for 8 weeks. Muscle strength was measured by raising the
upper body through a sit-up motion or tilting the upper body backward in the prone posture
and holding the positions. Pain was measured using the Numerical Pain Rating Scale
(NPRS), Korean Pain Catastrophizing Scale (K-PCS), and Tampa Scale of Kinesiophobia-11
(TSK-11) through questionnaires. Flexibility was measured using the finger-to-floor test
(FFT) and modified–modified Schober’s test (MMST). The activity disorder index was
evaluated using the Roland–Morris Disability Questionnaire (RMDQ).
In both groups, the 8-week-long intervention was performed once a day for a total
of 50 min, twice a week. Furthermore, the experimental and control groups underwent
the same physical therapy (hyperthermia, electrotherapy) for 20 min. Additionally, the
experimental group was administered PNE before each intervention. After 10 min of PNE
and physical therapy, 20 min of LSEs were performed. Meanwhile, the control group
performed only 30 min of LSEs after physical therapy. Two and three participants dropped
out of the experimental group and the control group, respectively. A total of 35 participants,
excluding the 5 who dropped out, completed the study.
The physical therapists who participated in the study had been trained for the LSEs
that were applied to the patients for >3 years in advance and were thus fully aware of
possible problems. The experiments were always conducted by the same therapist. The
same researcher conducted PNE before the start of the experiment (Figure 1).
J. Pers. Med. 2022, 12, 303 4 of 14

Figure 1. Flow diagram of total experimental procedure.

2.2.1. Pain Neuroscience Education

The PNE used in this study was aimed at lowering the threat value of pain, increasing
the participants’ knowledge of pain, and reconceptualizing pain. To achieve these aims, the
participants needed to understand that all pain is created, composed, and controlled by
the brain, and that pain symptoms are often associated with hypersensitivity of the central
nervous system and not with tissue damage [28]. Excerpts from the book Explain Pain [29]
were taken and verbally explained to the participants [23,30,31]. The education consisted
of a total of eight topics, with oral explanations provided with presentation materials. The
education was delivered to participants by the physical therapist who had completed a
PNE class and had more than five years of clinical experience. During training, all major
concepts of pain neurophysiology were explained and discussed [32]. PNE training was
conducted twice a week for 10 min before the start of all treatments (Table 1).

Table 1. Pain neuroscience education topics.

Weekly Training Topics (Training Time: 10 min Each)

1. Neurophysiology of pain
2. Nociception
3. Nociceptive pathways
Explain the basic theory of the structure of the brain and
nerves, the peripheral nervous system, and the central
nervous system by comparing to a mobile phone
or computer.
Explain and compare concepts and differences between
acute and chronic pain with real-world experiences and
emphasize the importance of exercise.
Explains the paths of pain sensation and
noxious/innoxious pain sensations, and highlights how
psychological aspects and thoughts affect pain.
J. Pers. Med. 2022, 12, 303 5 of 14

Table 1. Cont.

Weekly Training Topics (Training Time: 10 min Each)

4. Neurons and synapses
5. Action potential
6. Spinal inhibition and facilitation
7. Sensitization
8. Plasticity of the nervous system
The “How-to” of Teaching Patients About Pain.
Explain the structure and function of neurons and
synapses, the processes of electrical signals, and how the
patient’s thoughts can influence these signaling processes.
Describe action potentials and thresholds, and differences
in sensations felt by each person by comparing them to
signals and alarms generated by the body.
Explain the process of inhibition and promotion of the
spine by comparing the process of electrical signal
transmission and homeostasis and emphasize the change
in sensation according to the state of the body.
Explain the types of sensations, the process of transmitting
each sensation, and the differences, and emphasize the
understanding of pain through the gate control theory.
Explain the basic concept of neuroplasticity in relation to
changes in the brain caused by experience and learning
and emphasize positive changes through exercise.

2.2.2. LSE Training

LSE training was performed for 20–30 min per session, once a day, twice a week,
depending on the group. The difficulty was gradually increased from low to high. The LSE
intervention used in this study consisted of 11 exercise methods aimed at strengthening the
lumbar stabilization muscles such as the transversus abdominis, multifidus, and oblique ab-
dominal muscles. In addition, detailed explanations were provided to the participants [33]
by the physical therapist in charge, who had learned and trained with the postures for
≥3 years (Table 2).

Table 2. Lumbar stabilization exercise on the mat.

Item Training Method

In the supine position, place a towel under the sole of the foot, hold
Hamstring stretching the ends of the towel with both hands, extend the knee, lift the leg,
and repeat the stretching five times.
In the prone position, place both hands on the floor, stretch the
Abdominal stretching elbows and lift the upper body, and repeat the abdominal muscle
stretching five times.
In the lying position, bend one knee, pull back the lower leg with the
Quadriceps stretching
arm of the same side, and repeat the stretching five times.
In the crawling position, contract the abdominal muscles and bend
Cat–camel
and open the back five times.
In the knee-bent and lying position, pull the abdominal muscles to
Neutral position contract the transverse abdominal muscles and the pelvic floor
muscles isometrically, and maintain for 5 s. Repeat five times.
In the knee-bent and lying position, up the trunk to contract the
Curl up transverse abdominal muscles and maintain for 5 s. (arm position:
knee-chest-head) Repeat five times.
In the supine position, bend hip and knee 90 degree and lift from
Dead bug floor, flex the opposite shoulder and maintain for 5 s. Repeat
five times.
In the side lying position with knee flexion, left the pelvic off from the
Side bridge
floor and maintain for 5 s. Repeat five times.
J. Pers. Med. 2022, 12, 303 6 of 14

Table 2. Cont.

Item Training Method

In the prone position with arms straight overhead and legs fully
Superman extended, simultaneously lift arms and legs off the floor and maintain
for 5 s. Repeat five times.
In the supine position with knee flexion, left the hips off from the
Bridge
floor and maintain for 5 s. Repeat five times.
Quadruped position In the quadruped position, left the arm and leg off from the floor and
with lifting arm and leg maintain for 5 s. Repeat five times.
5 repetitions/1 set, rest time sets 20 s. Additional rest time was allowed when fatigue occurred or on a
patient’s request.

2.3. Outcome Measurements

2.3.1. Primary Outcome: Muscle Strength
Muscle strength was measured using sit-up and back-up motions. The same physical
therapist used a stopwatch to measure the retention time of the abdominal and back muscles
twice, and the average values were recorded in seconds. Muscle strength measurements
included abdominal muscle strength, back muscle strength, and muscle endurance. The
muscle strength of the abdomen and back was measured using the method of holding
sit-ups and tilting the back while in the prone position, respectively.
First, abdominal muscle strength was measured in seconds by raising the upper body
and holding the position. The participants lied on a mat, with the knees bent at 90 and the
arms crossed on the chest. The upper body was lifted by sitting up, the position was held,
and the elapsed time was measured. Second, the back muscle strength was measured in
seconds by leaning the upper body backward and holding the position. The participants
were positioned prone with both hands on the back of the waist. The back was lifted, the
back-up position was held, and the elapsed time was recorded.

2.3.2. Primary Outcome: Pain

Pain was measured using the NPRS, K-PCS, and TSK-11.
The NPRS is a self-report measurement tool that can be completed in <1 min. A score
range of 0–10 is set on the horizontal line, with 0 points on the left and 10 points on the
right, indicating the worst imaginable excruciating pain [34–36]. The NPRS is a simple
and highly reproducible method of expressing the degree of pain, with a high sensitivity,
interrater reliability of 0.90 [37], and test–retest reliability of 0.95–0.96 [38]. In this study,
the reliability of the tool was 0.95 (Cronbach’s alpha coefficient).
The K-PCS is the Korean version of the Pain Catastrophizing Scale (PCS) developed
by Sullivan et al. (1995) [39], which was modified and supplemented by Cho et al. [40].
The K-PCS consists of 13 questions, with three subfactors: ruminant thinking, hyperbolic
thinking, and helplessness [39]. On a Likert five-point scale, it is evaluated by summing
the scores, ranging from 0 point (not at all) to 4 points (always yes), with the total score
ranging from 0 to 52 points. The higher the total score, the higher the degree of negative and
exaggerated thoughts related to pain. The clinical judgment criteria were based on several
preceding studies, with a total score of 0–9 being low, 10–19 intermediate, 20–39 high, and
40–52 very high. The reliability of the tool was a Cronbach’s α of 0.93 in the study by
Cho et al. (2013). In this study, the reliability of the tool was a Cronbach’s alpha coefficient
of 0.84.
The TSK was devised as 17 items by Miller et al. (1991) [41], and Tkachuk et al. (2012) [42]
modified the tool to 11 items (TSK-11). The TSK-11 is composed of 11 items within two
factors (pathological somatic focus and activity avoidance) and is scored on a four-point
scale (from 1 to 4) for each item. The score range is 11–44 points, in which the higher the
score, the higher the level of motor fear [42]. The internal consistency of the TSK-11 is high,
with a Cronbach’s α coefficient of 0.80, and the reliability is moderate. The TSK-11 is a
J. Pers. Med. 2022, 12, 303 7 of 14

simple, reliable, and valid tool for measuring fear of movement and (re)injury in patients
with chronic pain. The internal agreement in this study was 0.86 [42].

2.3.3. Secondary Outcome: Flexibility

Flexibility was measured using the MMST and FFT. The measurements were per-
formed three times by the same physical therapist, and the average value was used.
The MMST is a method of measuring lumbar flexion to assess flexibility. This test can
separate and measure movements in the lumbar area using a tape. In the test method, with
the participant in an upright position, the examiner marked two landmarks with a black
pen: one landmark 5 cm below the midpoint of both sides of the participant’s posterior
superior iliac spine line and another point 10 cm above the line. The participant made
maximum effort to touch the floor, with the knees, elbows, and fingers open. In this state,
the distance between the two landmarks was measured with a tape measure and recorded.
The longer the distance, the better the flexibility. The validity and reliability were r = 0.67
and intraclass correlation coefficient (ICC) = 0.91, respectively [43].
In the FFT, the participants stood on a flat box without shoes, with the big toes of both
feet not crossing the corners of the box. The participants bent to reach the toes, and the
distance between the floor and fingers was measured. The upper-body forward lean test has
high validity (RS = −0.96) and high inter-rater and intra-rater reliability (ICC = 0.99) [44].

2.3.4. Secondary Outcome: Activity Disorder Index

The activity disorder index was assessed using the RMDQ, which measures the degree
of dysfunction caused by low back pain. It consists of a 0- to 24-point scale and is a
commonly used assessment method for low back pain disability parameters, such as the
Oswestry Disability Index, in clinical settings. The reliability (ICC) of the RMDQ is very
high at 0.932, and the Korean version of the RMDQ, which was proven reliable by Lee et al.,
was used in this study [45].

2.4. Statistical Analysis

SPSS statistical software (version 22.0; IBM, Chicago, IL, USA) was used for all statis-
tical analyses. The Shapiro–Wilk test was used to analyze the normal distribution of the
variables. The independent-samples t-test was performed to identify differences between
the groups. The paired t-test was used to compare the results before and after the interven-
tion. Lastly, the analysis of covariance was performed to identify differences between the
groups. The level of statistical significance was set at p < 0.05.

3. Results
We included more than 80% compliance to treatment for statistical analysis and
used data from 35 patients because 5 out of 40 dropped out due to personal reasons.
The demographic characteristics are shown in Table 3. No significant differences were
observed in the baseline values between the PNE plus LSE group and the LSE group for
all parameters.

3.1. Muscle Strength

The results of the comparison of pre-/post-test measures of the strength of the abdom-
inal and back muscles between the two groups are shown in Table 4. The strength of the
abdominal and back muscles significantly improved after the intervention within the PNE
plus LSE group and the LSE group (p < 0.05), with a significant difference between the
groups (p < 0.05). Covariance analysis was conducted to determine whether there was a
difference between the groups in terms of the level of change in the abdominal and back
muscles after intervention. The muscle strength was processed as a covariate (Table 4). The
results of the study showed statistically significant differences in the abdominal muscle
strength (F = 9.598; p = 0.005), and back muscle strength (F = 7.102; p = 0.014). These
results indicate that the PNE plus LSE group had a statistically significant improvement in
J. Pers. Med. 2022, 12, 303 8 of 14

the muscle strength compared to that in the LSE group, demonstrating that the training
program in this study was effective.

Table 3. Demographic data of the two groups (N = 35).

PNE + LSE LSE

Parameters t/x2 (p)
(n = 18) (n = 17)
Age (years) 68.89 (5.08) 71.29 (5.18) −1.386 (0.175)
Height (cm) 159.94 (3.42) 161.94 (3.63) −1.675 (0.103)
Weight (kg) 58.22 (2.94) 60.65 (6.09) −1.486 (0.151)
Obesity rate (%) 22.76 (0.94) 23.10 (1.86) −0.677 (0.505)
Duration of injury (months) 18.50 (6.767) 19.71 (5.871) 0.562 (0.578)
radiating pain (Yes/No) 3/15 2/15 0.172 (0.679)
Analgesic use (Yes/No) 4/14 3/14 0.114 (0.735)
Hypertension (Yes/No) 11/7 10/7 0.19 (0.890)
Hypercholesterolemia (Yes/No) 6/12 7/12 0.230 (0.631)
Previous history of cardiovascular
4/14 4/13 0.008 (0.927)
disease (Yes/No)
Data are mean (standard deviation). PNE, pain neuroscience education; LSE, lumbar stabilization exercise.

Table 4. Comparison of muscle strength within groups and between groups (N = 35).

Parameters Pre-Test Post-Test Group Difference, SS df MS Effect t(p)/F(p)

Mean (95% CI) Size
PNE + LSE 33.83 (5.29) 41.33 (4.67) −7.500 (−9.111 to –5.889) −9.820 (0.000)
Abdominal LSE 31.71 (4.78) 36.94 (4.25) −5.235 (−5.904 to –4.567) −16.599 (0.000)
muscle
strength Covariate 716.596 12 59.716 11.626 (0.000)
(sec) Group 49.302 1 49.302 0.304 9.598 (0.005)
Error 113.004 22 5.137
PNE + LSE 16.28 (1.93) 26.00 (2.22) −9.722 (−10.877 to –8.568) −17.769 (0.000)
Back LSE 15.76 (1.95) 23.18 (3.50) −7.412 (−9.007 to –5.816) −9.846 (0.000)
muscle
strength Covariate 189.558 12 15.796 2.1642 (0.056)
(sec) Group 51.851 1 51.851 0.244 7.102 (0.014)
Error 160.614 22 7.301
Data are mean (standard deviation). PNE, pain neuroscience education; LSE, lumbar stabilization exercise;
p < 0.05.

3.2. Pain
The results of comparison of pre-/post-test measures of pain in the NPRS, K-PCS,
and TSK-11 between two groups are shown in Table 5. Pain evaluated using the NPRS,
K-PCS, and TSK-11 significantly improved after the intervention within the PNE plus LSE
group and the LSE group (p < 0.001), and also showed significant differences between the
two groups (p < 0.05). Covariance analysis was conducted to determine whether there
was a difference between the groups in terms of the level of change in the pain after
intervention. The pain was processed as a covariate. The results of the study showed
statistically significant differences in the NPRS (F = 24.286; p < 0.001), K-PCS (F = 11.558;
p = 0.003), and TSK-11 (F = 13.179; p = 0.001). These results indicate that the PNE plus LSE
group had a statistically significant improvement in the pain compared to that in the LSE
group, demonstrating that the training program in this study was effective.

3.3. Flexibility
The results of the comparison of pre-/post-test measures of flexibility in FFT and
MMST between the two groups are shown in Table 6. The flexibility significantly improved
after the intervention within the PNE plus LSE group and the LSE group (p < 0.05). Co-
variance analysis was conducted to determine whether there was a difference between the
groups in terms of the level of change in the flexibility after intervention. The flexibility was
processed as a covariate. The results of the study showed statistically significant differences
in the FFT (F = 4.327; p = 0.049), but no significant difference in MMST (F = 3.451; p = 0.077).
J. Pers. Med. 2022, 12, 303 9 of 14

Table 5. Comparison of pain within groups and between groups (N = 35).

Parameters Pre-Test Post-Test Group Difference, SS df MS Effect t(p)/F(p)

Mean (95% CI) Size
PNE + LSE 4.67 (1.45) 2.78 (1.26) 1.89 (1.65 to 2.12) 17.000 (0.000)
LSE 4.59 (1.66) 3.47 (1.37) 1.12 (0.87 to 1.37) 9.500 (0.000)
NPRS
(points) Covariate 57.700 12 4.808 27.524 (0.000)
Group 4.243 1 4.243 0.525 24.286 (0.000)
Error 3.843 22 0.175
PNE + LSE 20.06 (2.53) 12.17 (2.61) 7.89 (7.02 to 8.76) 19.178 (0.000)
LSE 18.94 (2.56) 13.47 (2.76) 5.47 (4.81 to 6.13) 17.615 (0.000)
K-PCS
(points) Covariate 197.000 12 16.417 6.381 (0.000)
Group 29.736 1 29.736 0.344 11.558 (0.003)
Error 56.600 22 2.573
PNE + LSE 54.92 (9.93) 38.13 (7.89) 16.79 (13.99 to 19.59) 12.655 (0.000)
LSE 56.95 (6.93) 45.72 (7.31) 11.23 (8.70 to 13.76) 9.414 (0.000)
TSK-11
(%) Covariate 1949.755 12 162.480 7.614 (0.000)
Group 281.246 1 281.246 0.375 13.179 (0.001)
Error 469.497 22 21.341
Data are mean (standard deviation). PNE, pain neuroscience education; LSE, lumbar stabilization exercise; NPRS,
Numerical Pain Rating Scale; K-PCS, Korean Pain Catastrophizing Scale; TSK-11, Tampa Scale of Kinesiophobia-11;
p < 0.05.

Table 6. Comparison of flexibility within groups and between groups (N = 35).

Parameters Pre-Test Post-Test Group Difference, Mean SS df MS Effect t(p)/F(p)

(95% CI) Size

PNE + LSE −1.83 −1.16 −0.66 (−0.99 to −0.33) −4.225 (0.001)

(3.73) (3.91)
FFT LSE 0.17 (3.52) 0.58 (3.51) −0.41 (−0.72 to −0.10) −2.820 (0.012)
(cm) Covariate 476.447 12 39.704 89.906 (0.000)
Group 1.911 1 1.911 0.164 4.327 (0.049)
Error 9.716 22 0.442
PNE + LSE 3.51 (0.78) 3.71 (0.74) −0.20 (−0.27 to –0.12) −5.532 (0.000)
LSE 3.23 (0.84) 3.37 (0.83) −0.14 (−0.19 to −0.08) −5.470 (0.000)
MMST
(cm) Covariate 22.141 12 1.845 126.527 (0.000)
Group 0.050 1 0.050 0.077 3.451 (0.077)
Error 0.31 22 0.015
Data are mean (standard deviation). PNE, pain neuroscience education; LSE, lumbar stabilization exercise; FFT,
finger-to-floor test; MMST, modified–modified Schober’s test; p < 0.05.

3.4. Activity Disorder

The results of comparison of pre-/post-test measures of activity disorder in the RMDQ
between the two groups are shown in Table 7. The RMDQ score significantly improved
after the intervention within the PNE plus LSE group and the LSE group (p < 0.05).

Table 7. Comparison of activity disorder within groups and between groups (N = 35).

Parameters Pre-Test Post-Test Group Difference, Mean SS df MS Effect t(p)/F(p)

(95% CI) Size
PNE + LSE 9.94 (1.58) 6.06 (1.79) 3.89 (3.13 to 4.65) 10.786 (0.000)
LSE 10.94 (1.56) 7.18 (1.97) 3.76 (3.23 to 4.29) 15.033 (0.000)
RMDQ
(points) Covariate 80.019 12 6.668 3.032 (0.012)
Group 0.179 1 0.179 0.004 0.081 (0.778)
Error 48.381 22 2.199
Data are mean (standard deviation). PNE, pain neuroscience education; LSE, lumbar stabilization exercise; RMDQ,
Roland–Morris disability questionnaire; p < 0.05.

Covariance analysis was conducted to determine whether there was a difference

between the groups in terms of the level of change in the activity disorder after intervention.
J. Pers. Med. 2022, 12, 303 10 of 14

The activity disorder was processed as a covariate. The results of the study showed
statistically no significant differences in the RMDQ score (F = 0.081; p = 0.778).

4. Discussion
This study found the effects of PNE combined LSEs on muscle strength and pain in
female patients for chronic low back pain.
In the comparison of muscle strength between before and after the intervention in this
study, the abdominal muscle strength of the experimental group increased from 33.83 to
41.33 s, and the back strength increased from 16.28 to 26.00 s, with significant differences
(p < 0.05). In the comparison of the difference in the amount of change between the two
groups, the experimental group showed a significantly higher difference in both abdominal
strength and back strength than the control group (p < 0.05), indicating that the combination
of PNE and LSEs is more effective in improving muscle strength in patients with chronic
low back pain.
In a study by Rosa Andias et al. (2018) [46], muscle endurance was significantly
improved before and after the experiment in the experimental group (before and after
difference, +47.5 s) and in the control group (before and after difference, +14.2 s). The
comparison between the two groups also showed a significant difference. It has been
shown that neuroscience education is effective in improving muscle strength. In this study,
PNE increased the patients’ interest in functional activity and exercise and motivated
them to perform more frequent and intense activities, thereby improving physical ability
and reducing pain [47]. In addition, PNE has been reported to have a positive effect
of changing incorrect pain beliefs and incorrect movements of the lower back [23], thus
allowing patients to more actively participate in the LSE program without fear of exercise.
The LSE intervention time of the experimental group was 10 min shorter than that of the
control group; however, the lumbar muscle strength was further increased because of the
additional exercise performed at home.
In the comparison of the change in pain before and after the intervention in this study,
the pain score (NPRS) of the experimental group ranged from 4.67 to 2.78 points. Although
we achieved statistical significance between groups, this does not mean clinical meaningful
results. The minimum clinically important difference (MCID) of NPRS for low back pain
is a 2 point change [48]. The K-PCS score decreased from 20.06 to 12.17 points, and the
TSK-11 score decreased from 54.92% to 38.13%, with a significant difference between before
and after the experiment (p < 0.05). In the comparison of the difference in the amount
of change between the two groups, the experimental group showed significantly better
improvement than the control group in terms of pain score, catastrophic level of pain,
and level of motor fear (p < 0.05). The PCS score’s minimal detectable change (MDC)
was reported to be 9.1 points for low back pain, and our results did not reach a clinically
meaningful difference [49].
In a study by Pires et al. (2015) [50], 62 patients with chronic low back pain were
divided into 30 participants in the experimental group who underwent PNE and aquatic
exercise training and 32 participants who performed water exercises alone, with 12 aquatic
exercise programs applied for 6 weeks. In the case of the experimental group, two PNE
programs were applied before the aquatic exercises. The pain score, motor fear level, and
dysfunction before and after the experiment were measured at three time points: before,
6 weeks after, and 3 months after the experiment. The pain score of the experimental group
changed from 43.4 to 20.6 points after 6 weeks and to 18.0 points after 3 months. In the
case of the control group, the score decreased from 42.4 to 27.6 points after 6 weeks and
then increased again to 35.8 points after 3 months. In the case of motor fear level, the score
in the experimental group decreased from 28.6 to 25.2 points after 6 weeks and to 23.2
points after 3 months. In the control group, the score decreased from 29.1 to 27.5 points
after 6 weeks and to 26.5 points after 3 months. As a result, only the pain score showed
statistical significance in the comparison between groups.
J. Pers. Med. 2022, 12, 303 11 of 14

The PNE used in this study changes misconceptions or coping strategies for pain
and disease, thereby improving pain and showing a positive effect on learning normal
movements and activities [51]. It is believed that such an education has a positive effect on
pain improvement. However, previous research has shown that although PNE is effective
in reducing pain when combined with an exercise program, as observed in this study, pain
may increase again after a period if education is not provided. Therefore, the number of
training sessions might also have an effect on the therapeutic outcome and can have a
positive effect on long-term pain improvement.
In a study by Malfliet et al. (2018), 120 patients with nonspecific chronic spinal pain
were divided into an experimental group that received PNE and a control group that
received education about the biological properties of the back and neck. The levels of motor
fear and catastrophic pain were evaluated before and after training. As a result, the level of
motor fear decreased from 34.37 to 30.32 points in the experimental group and from 36.72
to 35.73 points in the control group, with a statistically significant difference within and be-
tween groups, indicating that PNE training was more effective (p < 0.05). Woby et al. (2004)
reported that pain reconceptualization through PNE decreases the threshold for pain and
changes incorrect beliefs and thoughts about the causes of pain [52]. Therefore, previous
studies indicate that although immediate and positive effects appear after only a short
period of education, continuing such education may have considerable long-term effects.
More studies should be conducted in the future to determine the number of sessions and
the duration of education that can show the most appropriate and the greatest effect, in
order to establish the most efficient treatment method.
With respect to the change in flexibility before and after the intervention in this study,
the FFT result in the experimental group increased from −1.83 cm (before the experiment)
to −1.16 cm (after the experiment). The MMST result increased from 3.51 to 3.71 cm in the
experimental group. A significant difference was observed in the FFT and MMST within
groups (p < 0.05), but the FFT only showed a significant difference between groups (p < 0.05).
These results do not reveal the clinical significance. In a future study, a systematic and
balanced exercise program that can improve flexibility as well as muscle strength and pain
should be applied, and the component involving exercising at home should be monitored
daily to provide motivation. We believe that better research results will emerge if this can
be efficiently implemented.
The changes in the activity disorder index before and after the intervention in this
study were evaluated using the RMDQ. As a result, the activity disorder index in the
experimental group decreased from 9.94 to 6.06 points, showing significant differences
between before and after the experiment (p < 0.05). However, no significant differences
between the two groups were observed, and thus it is unknown whether the combination
of PNE and LSEs has a positive effect on activity disorder index in patients with chronic low
back pain. Moseley et al. (2004) divided a total of 58 patients with chronic low back pain into
31 participants in the experimental group who received PNE and 27 control participants
who received education on the anatomy and physiology of the back. The activity disorder
index was evaluated using the RMDQ before and after the experiment. As a result, the
activity disorder index of the experimental group decreased from 15 to 14 points, whereas
that of the control group increased from 15 to 16 points, with a statistically significant
difference (p < 0.05). Although our result showed no statistical significance between
the two groups in RMDQ, we achieved a clinically significant MCID of RMDQ i.e., the
recommended 2.5 points [53].
This study had some limitations. First, there is a limit to generalizing our results, as
the number of participants was small, the patient’s clinical profile, such as risk factors or
comorbidities was a limited reflection, and the data were limited to one hospital in Seoul.
Second, as the frequency of confirming the effect was low (twice a week), the total interven-
tion time was somewhat insufficient relative to the study period. Third, in providing PNE,
we attempted to use supplemental materials such as pictures or images to improve the ease
of understanding of the theoretical contents for older patients; however, there was some
J. Pers. Med. 2022, 12, 303 12 of 14

difficulty. Therefore, future studies will need to not only develop educational programs
using simpler words and various data that general patients can easily understand, but also
to include more participants. In addition, in the process of performing LSEs, there was a
difference in the participants’ understanding of the exercise. In the first week, the time for
re-education about individual muscles and the principles of exercise accounted for >50% of
the exercise time. Therefore, in future studies, it should be considered that participants with
chronic low back pain may have lower awareness of posture or movements than normal
participants, and it is necessary to ensure sufficient understanding of the participants before
conducting the program.

5. Conclusions
This study proved that the combination of the pain neuroscience education combined
with lumbar stabilization exercises is more effective than lumbar stabilization exercises
alone as a treatment method for improving muscle strength and reducing pain in female
patients with chronic low back pain. However, further studies on various educational and
exercise programs with large samples are needed.

Author Contributions: Conceptualization, K.-S.K. and B.-H.L.; Data curation, K.-S.K., J.A. and J.-O.K.;
Formal analysis, K.-S.K.; Methodology, K.-S.K., J.A., J.-O.K. and M.-Y.L.; Project administration,
M.-Y.L. and B.-H.L.; Supervision, M.-Y.L. and B.-H.L.; Writing—original draft, K.-S.K., J.A. and
J.-O.K.; Writing—review & editing, B.-H.L. All authors have read and agreed to the published version
of the manuscript.
Funding: This paper was supported by the Academic Research Fund of Myung Ki (MIKE) Hong in
2021 (RI12021052).
Institutional Review Board Statement: This study was conducted in accordance with the Declara-
tion of Helsinki and was approved by the institutional review board of Sahmyook University in
the Republic of Korea (Seoul, Korea, 2-1040781-A-N-012020081HR). The protocol of this trial was
retrospectively registered in the Clinical Research Information Service of the Republic of Korea
(KCT0005499).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors have no conflict of interest to declare.

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